[Clinical itinerary for heart failure: a program designed by primary care practitioners in Geneva]. / Itinéraire clinique pour l'insuffisance cardiaque: un programme conçu par des médecins de premier recours genevois.

Episodes of heart failure impact on patients' quality of life as well as their morbidity and mortality. This article describes a series of interventions designed by a group of primary care practitioners in Geneva. Some interventions aim to improve patients' autonomy in identifying the first signs of heart failure to act immediately. Others focus on patients' motivation to adopt appropriate behaviours (physical activity, etc.). And finally others have the objective to improve coordination between ambulatory and hospital care, as well as the transmission of clinical information. The implementation of these interventions highlights the need for individualised objectives of care in complex cases where patients have several co-morbidities and/or complicated social situations. In these situations an interdisciplinary approach is also essential.

[Diagnosis and management of pharyngitis]. / Diagnostic et prise en charge de la pharyngite de l'adulte.

Although most pharyngitis are caused by viruses, up to 75% of patients visiting for a sore throat receive an antibiotic. As the performance of clinical features is poor a throat swab may help to differentiate a pharyngitis caused by a Group A beta3-hemolytic Streptococcus (GABHS) from other causes. A recent study tested and validated a new strategy combining a rapid test detecting GABHS and a clinical score with 2 or more of the four criteria (fever more than 38 degrees, tender cervical nodes, no cough and tonsillar exsudate). This strategy is cost-effective and limits antibiotic prescription to patients with GABHS. If the score is below two, a symptomatic treatment without antibiotic is recommended.

Comparison of four strategies for diagnosing deep vein thrombosis: a cost-effectiveness analysis.

PURPOSE: Four strategies for the diagnosis of deep vein thrombosis have been validated recently. The strategies use various combinations of assessment of a patient's clinical probability of having deep venous thrombosis, serial lower limb venous compression ultrasonography, and measurement of plasma D-dimer levels. We compared the cost-effectiveness of these diagnostic strategies. MATERIALS AND METHODS: We performed a formal cost-effectiveness analysis using a decision-analysis model. Outcomes considered were costs per patient, 3-month quality-adjusted survival, number of lives saved per 1,000 patients, and incremental costs per quality-adjusted life-year (QALY) gained. RESULTS: Under baseline conditions, with a 24% prevalence of deep vein thrombosis in tested patients, the effectiveness of all strategies was similar (4.6 to 4.8 lives saved per 1,000 patients managed). The most expensive strategy was serial ultrasound (repeat ultrasound on day 7 in all patients with a normal initial ultrasound) at a cost-effectiveness of $10,716 per additional QALY. Performing a repeat ultrasound only in patients with an elevated D-dimer level (serial ultrasound with D-dimer) was somewhat less expensive at $10,281 per additional QALY. Taking clinical probability into account by repeating ultrasound only in patients with an intermediate clinical probability of deep vein thrombosis (risk-based serial ultrasound) yielded further savings and cost $10,090 per additional QALY. The least expensive and most cost-effective option was to perform D-dimer as the initial test, followed by a single ultrasound if the D-dimer level was abnormal, and by phlebography in patients with a normal ultrasound and a high clinical probability of deep vein thrombosis (D-dimer with risk-based single ultrasound) at $8,897 per additional QALY. This strategy allowed a 17% reduction in incremental costs compared with the most expensive algorithm and reduced resource consumption (70 ultrasound procedures per 100 patients managed vs 130 to 170 with the other diagnostic strategies). CONCLUSIONS: Combining clinical probability and D-dimer with a single ultrasound in the diagnostic workup of patients with possible deep vein thrombosis is highly cost-effective, allowing a reduction in costs and resource use without any substantial increase in mortality. Serial ultrasonography is less cost-effective.

Rare urogenital anomaly causing discharge and pain. A case report.

BACKGROUND: Patients with müllerian anomalies usually seek help because of poor reproductive performance. CASE: A 16-year-old, white woman presented with a persistent, brown vaginal discharge and right lower quadrant pain. Because of voluntary guarding, the uterus could not be palpated on bimanual examination. However, transvaginal sonography showed a right cystic mass and a slightly binodular contour of the uterus. Laparoscopic evaluation revealed the presence of a bicornuate uterus. A hysterosalpingogram showed a double uterine cavity and cervical canal below the right uterine cavity, leading to a cystic, paravaginal mass. Incision of the mass and drainage of its chocolate-brown fluid content revealed a small, blind vagina leading to a second cervix. Using a wire probe, an isthmic communication was demonstrated between the two uterine cavities, leading to the final diagnosis of bicornuate uterus, laterally communicating, with a double cervix and vagina, unilaterally blind. CONCLUSION: Awareness of the possibility of this clinically puzzling anomaly will avoid delayed or unnecessary surgical treatment.

Laparoscopy using a simplified open technique. A review of 585 cases.

Laparoscopy was carried out using a simplified open method on 585 patients. In the group, 173 (29.5%) had undergone a previous laparoscopy or laparotomy, 28 (4.8%) suffered from gross obesity and 1 patient had a large umbilical hernia. Laparoscopy was diagnostic in 216 (37%) patients and operative in 369 (63%). In this series there were no technical failures or major complications; the incidence of minor complications was 2.7%. The above results seem to suggest that open laparoscopy compared to the closed method may offer the advantage of a lack of contraindications secondary to previous surgery, no risk of failure with unintended laparotomy and, possibly, decreased postoperative discomfort. A larger, randomized series to settle the controversy between closed and open laparoscopy regarding the safety differences between the two approaches may result in more widespread use of the open technique.

Legal liability in the use of ultrasound by office-based obstetricians.

Ultrasound has proved to be a valuable diagnostic tool in the practice of obstetrics. Its rapidly increasing use by the office-based obstetrician, however, has opened a potential new area of legal vulnerability. The malpractice liability that may arise from its use is reviewed and practical ways to avoid it are considered.

Conventional vs. open laparoscopy.

Compared with the closed technique, open laparoscopy offers several advantages, including fewer contraindications, a simpler technique, lower operative risk, easier establishment and release of pneumoperitoneum and fewer complications.

Microsurgical reversal of tubal sterilization: a review.

PIP: To meet the demand of patients who regret their tubal sterilization, microsurgical techniques have been developed to reverse the process. This discussion reappraises the role of such techniques and their efficacy. Of all the tubal sterilization methods, those with the least amount of tubal destruction and with preservation of fimbriae provide the best chance for a reversal. The chances for successful reversal seem to be better in patients who undergo the Pomeroy method of sterilization or in those in whom the tubal occlusion is achieved by the use of clips or rings. Tubal fulguration by laparoscopy offers less promise for reversal, especially when the multiple burn technique is used, because of the excessive tubal destruction caused. Tubal uterine implantations consist of the implantation of either the isthmic or the ampullary segment of the tube into the uterus. The sterilization best suited for this method of reversal is one in which the portion of the tube next to the uterus has been destroyed, i.e., when a cornual anastomosis is not feasible. This is frequently the case following tubal fulguration. Tubal anastomisis can be divided in 6 types according to the segment involved: intramural-isthmic; intramural-ampullary; isthmic-isthmic; isthmic-ampullary; ampullary-ampullary; and ampullary-infundibular. Technically the easiest ones to reverse are those in which the proximal and distal lumina are of relatively equal size. The best results are generally obtained with anastomisis between 2 tubal segments without excessive caliber disparity. Salpingoneostomy involves the creation of a new tubal osteum. The tubal sterilization most appropriate for reversal with a salpingoneostomy is a fimbriectomy. Depending upon whether the latter is distal or medial, the salpingoneostomy can be terminal, midampullary, or isthmic. Patients in whom reversal of sterilization is contraindicated are identified. The reversal of sterilization by microsurgery involves gentle handling of tissue, meticulous hemostasis, the use of delicate instruments and fine sutures, careful dissection, accurate tissue approximation, and magnification techniques. A comparative analysis of clinical results revealed that the results achieved with the microscopic technique for the reversal of sterilization appeared to be significantly better than with a gross technique. Tubal anastomisis appears to be more often successful than implantation or salpingeoneostomy. Until more valid statistical data are collected, it can be stated that microsurgery offers a potential increase in the intrauterine pregnancy rate when used to reverse tubal sterilization. The cost and the increased risk of ectopic pregnancy associated with reanastomosis obligate the gynecologist to offer appropriate counseling to patients requesting sterilization.^ieng